Role of

Occupational Therapy

and Physiotherapy in

Paediatric Burns

Beth Kershaw Naylor – Physiotherapist

Chriscelle Calladine – Occupational Therapist

Frenchay Hospital, Bristol

Aims of Presentation

Therapists’ Role

Techniques Used

Different types of scarring

Identifying those at risk of

problem scarring

Treatment for scars

Barbara Russell Children’s

Unit Therapy Team

Occupational Therapists

Alison Guy

Chriscelle Calladine

Physiotherapists

Amanda Dufley

Beth Kershaw-Naylor

Therapists Role Maintain correct joint/postural positioning

and protect wound as it heals

Promote early mobility and play

Prevent deformity from contracture

Increase exercise tolerance

Educate regarding skin care and desensitisation

Liaise and educate community therapists in preparation for discharge and post discharge

Assess for equipment needs

Scar Management

Active Exercise Through

Play Therapy

• Maintain/ improve function

• Encourage normal development

• Increase/maintain ROM

• Increase exercise tolerance

• Increase strength

ROM Exercises and

Stretches

Movement of joints through range either

actively or passively

Splints

Thermoplastic (mouldable at 60º) – keep away from heat

Washed with soap in luke warm water

Should not have any damage, or straps missing

Should be comfortable and not cause swelling or pain.

• to position correctly

• to prevent contracture,

deformity and loss of

function

Splints

Hands, (POSI)

Elbow, (extension)

Knee, (extension)

Ankles, (90 degrees dorsiflexion)

Axilla, aeroplane splint, (90 degrees)

Neck

Scar Management

To control and treat problematic scarring

To improve cosmetic outcome

To prevent contractures and improve function

To reduce pain and discomfort

Aims

How is a scar different to

normal skin?

Quality and texture different

Collagen type and formation

Tendency to contract

There are no hair follicles or

sweat glands

More susceptible to ultra violet

radiation

Scar: The fibrous tissue that replaces

normal tissue destroyed by injury or

disease

Types of scarring

Flat Pale Scar -

normally slightly paler than the

surrounding skin, flat and soft

Atrophic –

sunken or

pitted scar

e.g. acne or

chickenpox

Problem Scarring

Hypertrophic Scar A widened or red, raised scar

Often itchy or painful

Problem Scarring

Keloid Scar An abnormal scar that grows

beyond the boundaries of the

original site of injury

Excessive Collagen

Scar much larger than original

site of injury

Less responsive to treatment

Problem Scarring

Contracture Scar Problem scars can lead to

contracture - where the scar

causes tightening of the skin which

in turn may effect movement

Wound healing is different to

scar maturation

Problem scarring may not be seen until 2-4

months after wound healing has occurred.

A problem scar can take up to 2 years to

mature

Who is at risk of problem

scarring?

Grafted burns 70% more likely

Burn Injury taking longer than 3 weeks to heal

Infection

Depth of burn

Site on body

Skin Type

History of scarring

Cream and Massage

Increased scar pliability and

decreased scar banding have

been reported - Roques (2002)

Reported benefits –

• Improved skin quality

• Decreased sensitivity

• Increased cutaneous

hydration

• Improved scar quality

• Better acceptance of scar by

patient - Field et al (2000)

Various techniques- none

validated

Silicone

Silicone Sheeting

Can be washed in mild soap

and warm water

Should last up to 6 weeks

Silicone Gel

Normally applied 2x daily

Area should be

washed before

reapplication

Check for rash

• Cream, sheet, spray or elastomer

• Reasonable evidence exists of its efficacy

but mechanism not well understood

• Gradiates the oxygen and moisture flow of

the skin Niessen et al (1998), Gilman (2003)

Pressure Therapy

Used since 1860 in the form of elastic bandages

Little scientific (but lots of experiential) evidence to

support use

Pressure controls collagen synthesis and encourages

realignment of collagen bundles Aityeh (2007)

The use of pressure garments to treat burns scars

A pressure garment is a made to

measure specially designed article of

clothing that is worn over burn scars.

They are normally

made from a fabric

called PowerNet, a

Lycra fabric which

should fit like a

second skin.

Pressure Therapy

Average pressure applied = 25mmHg

In order for the garment to work they must be: Applied as soon as possible after healing has occurred

Worn 24 hours a day, removed only for creaming and

bathing

Washed regularly following the manufacturers guidelines to

maintain elasticity

Fitted accurately and reviewed regularly

Other scar management

techniques

Surgery

Corticosteroid Injections

Radiotherapy

Laser Therapy

Cryotherapy

Micro pore tape

Dermobrasion

Topical Vitamin E

Hydrotherapy

Ultrasound

Pulsed electrical stimulation

Thomas A. Mustoe et al 2002

Anecdotal therapies

Camouflage

Assessment

Commence assessment and appropriate treatment as soon as the wound has healed

Assessment is carried out using a number of techniques and standardised scar scales

Considerations when

selecting treatment

Severity of scar

Location and size of scar

Length of time to heal

Number of risk factors, e.g. previous problematic scarring

PMH

Allergies

Age

Lifestyle of patient

Functional and cognitive ability of patient and available support network

Patient preference

Ability to attend appointments

Cost

Management

Follow-up for pressure

therapy generally:

Children every 2 months,

Adults every 3 months

Follow-up for patients using silicone only is judged on an individual basis

Follow-up for 2 years or until scarring matures

Aim for scarring to be soft, flat, pale, pain free and itch free and the individual to have returned to as close to their normal level as function as possible

Other considerations

Pain Management

Itch and hypersensitivity

Psychological health

Functional Ability

Return to work/school/leisure

Cosmetic techniques

References

Akita et al (2006) The quality of paediatric burn scars is improved by early administration of

basic fibroblast growth factor. Journal of burn care and research Vol27 page 333

Atiyeh, B (2007)Nonsurgical management of hypertrophic scars: Evidence-based therapies,

standard practices, and emerging methods. Journal of Aesth Plastic surgery. Vol31 page

468-492

Brusselaers et al (2010) Burn scar assessment: A systematic review of different scar scales.

Journal of surgical research Vol164 pages e115-e123

Field et al (2000) Post burn itching, pain and psychological symptoms are reduced with

massage therapy. Journal of burn care and rehabilitation Vol21 page 189

Gilman (2003) Silicone sheet for treatment and prevention of hypertrophic scar: A new

proposal for the mechanism of efficacy. Journal of wound repair and regeneration Vol11,

page 2365-236

Loladze et al (2005) Use of bilidase for the treatment of experimental hypertrophic post burn

cicatrices. Bull Exp Bio Med 139:98

Niessan F (1998)The use of silicon occlusive sheeting and silicon occlusive gel in the

prevention of hypertrophic scar formation. Journal of plastic and reconstructive surgery

Vol102 page 1962

Regina Fearmonti, MD et al (2010) Journal of Plastic Surgery. Vol10 1937-5719 June 21

2010

Thomas A. Mustoe et al (2002) International Clinical Recommendations on Scar

Management. Plastic and Reconstructive surgery. Vol110, No2 Aug 2002

Kristine M. Bombaro et al.(2003) What is the prevalence of hypertrophic scarring following

burns. Burns 29 (2003)299-302